Evidence-Based Orthodontics for the 21St Century

Interclass & São Leopoldo Mandic LITOI

Evidence-based orthodontics for the 21st century. Ackerman M. [email protected]

BACKGROUND: This article examines some of the data-driven advances in clinical orthodontics and how they might influence the decision-making process in the specialty. TYPES OF STUDIES REVIEWED: Nearly 100 years of orthodontic study has focused on two issues: one-phase versus two-phase treatment of Class II malocclusion and extraction versus nonextraction treatment of arch perimeter deficiencies. The author addresses these issues by presenting data from the first randomized clinical trial in orthodontics and from a survey of the current literature. RESULTS: The clinical trial involved subjects who had Class II malocclusion. The researchers who conducted the trial found no difference in the quality of the dental occlusion between the children who had early treatment and those who did not, as judged by both an occlusal index (Peer Assessment Rating scores) and the percentages of the subjects with excellent and less-than-optimal outcomes. Early treatment did not reduce the eventual need for orthognathic surgery. In a separate study, a researcher reported that the maxillary arch perimeter could be increased by 3 to 4 millimeters by using rapid palatal expansion, or RPE, providing space for incisor alignment to resolve crowding. The author concluded that any added benefit of RPE treatment in patients without a crossbite might be "challenging to define." CLINICAL IMPLICATIONS: The challenge facing orthodontists in the 21st century is the need to integrate the accrued scientific evidence into clinical orthodontic practice. PMID: 15005431 [PubMed - in process]

[In Process Citation] [Article in Dutch] van der Linden FP, Schmiedel WJ, Bijlstra RJ. [email protected]

After clarifying the role and significance of the European Federations of Orthodontic Specialists Associations (EFOSA), the results of a recent survey on the situation of the Speciality of Orthodontics in Europe are presented. Among the many items included are the recognition and availability of orthodontic specialists, their training, their working conditions, the height of the charged fees and the present insurance and refunding systems. PMID: 15004984 [PubMed - in process] [In Process Citation] [Article in Dutch] Kuijpers-Jagtman AM. Afdeling Orthodontie en Orale Biologie, Universitair Medisch Centrum Sint Radboud, Postbus 9101 6500 HB Nijmegen. [email protected]

Clinical performance can be kept up to date by learning how to practice evidence-based orthodontics, by seeking and appraising evidence-based summaries from the literature and by applying evidence-based strategies to change clinical behaviour. A MEDLINE search over the period 1990-2000 identified 8345 publications on clinical orthodontic subjects. Of these articles 49.5% was published in five specific orthodontic journals, while the others were published in about seventy other journals making it difficult for the clinician to stay current easily. Systematic reviews are an efficient and reliable source of information, but due to a lack of well-designed randomised clinical trials systematic reviews in orthodontics are still rare. PMID: 15004985 [PubMed - in process] A customized distraction device for alveolar ridge augmentation and alignment of ankylosed teeth. Nocini PF, De Santis D, Ferrari F, Bertele GP. Oral and Maxillofacial Surgery, Faculty of Medicine, University of Verona, Italy. [email protected] The purpose of this study was to develop an extraosseous, tooth-supported miniature intraoral device that could produce prosthetically driven bone distraction of small atrophic alveolar ridge segments. Extraosseous distraction requires that the distraction device be anchored to a dental implant previously placed into the ridge according to its anatomic axis. A distractor can also correct the position of implants placed in young patients before skeletal growth is completed. Similarly, it allows the alignment of ankylosed teeth not treatable by orthodontics. The device is made of (1) an engine consisting of an orthodontic micrometric screw; (2) a joint between the implant and the engine, ie, the ball attachment/o-ring system; and (3) an anchorage system to the oral cavity provided by an orthodontic appliance and a mini-implant for possible additional support. Surgery involves an osteotomy of the atrophic alveolar ridge segment, incorporating the implant, from the basal bone; Interclass & São Leopoldo Mandic LITOI afterward the device can be applied and distraction of the segment can be carried out. Distraction was successfully performed in 3 clinical cases: 2 bone-implant segments and 1 bone-ankylosed tooth segment. All cases were clinically uneventful. This mini-device for osteogenic distraction of small atrophic ridge segments can provide for accurate and precise ridge augmentation, as is required for ideal prosthetic rehabilitation.

Publication Types:  Case Reports

Effectiveness of the Innsbruck Sensorimotor Activator and Regulator in improving saliva control in children with cerebral palsy. Johnson HM, Reid SM, Hazard CJ, Lucas JO, Desai M, Reddihough DS. Communication Resource Centre, SCOPE, 830 Whitehorse Road, Box Hill, 3128, Australia. [email protected]

The aim of this study was to determine the effectiveness of an intraoral appliance, the Innsbruck Sensorimotor Activator and Regulator (ISMAR), in improving drooling and eating skills in a group of children with cerebral palsy, and to determine which factors might indicate good candidates for this type of treatment. Eighteen children (13 males, five females; mean age 7 years 10 months, range 4 to 13 years) were selected. Measures of drooling and feeding skills were taken at baseline, at the completion of a 6-month control phase, and at two more 6-monthly time points after the ISMAR was fitted. Children varied greatly in both the length of time taken to tolerate wearing the ISMAR and duration for which the appliance was worn. Only six children (four females, two males) completed the full study. Their motor disabilities were athetosis (n=3), spastic quadriplegia (n=2), and hypotonia (n=1); four of the six children used a wheelchair for locomotion. None had epilepsy and none had greater than mild cognitive impairment. For these children drooling severity scores and eating and drinking skills improved significantly over the treatment period in comparison with the control phase. We conclude that the ISMAR remains a valid option in improving drooling in children and merits further study.

Publication Types: Clinical Trial Behavior of partially formed roots of teeth submitted to orthodontic movement. da Silva Filho OG, Mendes Ode F, Ozawa TO, Ferrari Junior FM, Correa TM.

Hospital for Rehabilitation of Craniofacial Anomalies, University of Sao Paulo, Bauru, Brazil. [email protected]

The occurrence of root resorption in orthodontically treated permanent incisors with partially formed roots was investigated using periapical radiographs taken before and after the orthodontic leveling in the mixed dentition. The mean age at the beginning of treatment was 9 years and the mean treatment time was 7.1 months. The findings showed that the orthodontic movement during root formation causes no root resorption. The longitudinal follow-up showed that incompletely formed roots developed normally.

Publication Types: Mandibular pendex spring appliance for use in mixed dentition.

Giancotti A, Radico P, Docimo R.

University of Rome Tor Vergata, Fatebenefratelli Hospital, Isola Tiberina, Roma, Department of Orthodontics, Italy. [email protected]

Loss of space in the mandibular arch is a common occurrence due to several different causes such as caries, trauma or iatrogenic damage. This paper describes a new TMA spring used in mixed dentition for space regaining in the mandibular arch. A clinical report is presented and the advantages of the method are discussed.

Orthodontics. Part 5: Appliance choices. Interclass & São Leopoldo Mandic LITOI Roberts-Harry D, Sandy J.

Orthodontic Department, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU.

There are bewildering array of different orthodontic appliances. However, they fall into four main categories of removable, fixed, functional and extra-oral devices. The appliance has to be selected with care and used correctly as inappropriate use can make the malocclusion worse. Removable appliances are only capable of very simple movements whereas fixed appliances are sophisticated devices, which can precisely position the teeth. Functional appliances are useful in difficult cases and are primarily used for Class II Division I malocciusions. Extra-oral devices are used to re- enforce anchorage and can be an aid in both opening and closing spaces.

PMID: 14966494 [PubMed - indexed for MEDLINE]

Orthodontics. Part 7: Fact and fantasy in orthodontics.

Williams P, Roberts-Harry D, Sandy J.

Division of Child Dental Health, University of Bristol Dental School, Lower Maudlin Street, Bristol BS1 2LY.

Clinical research has previously lacked good methodology and much opinion was based on anecdote which is widely regarded as the weakest form of clinical evidence. There are few randomised control trials in orthodontics which support or refute areas of dogma. The number of randomised control trials is increasing significantly. There is currently however no good evidence that orthodontics causes or cures temporomandibular joint dysfunction, that appropriate extractions in orthodontics ruin patients' profiles, or that the orthodontist is able to significantly influence facial growth with appliances.

Two different degrees of mandibular advancement with a dental appliance in treatment of patients with mild to moderate obstructive sleep apnea.

Tegelberg A, Walker-Engstrom ML, Vestling O, Wilhelmsson B.

Department of Stomatognathic Physiology, Centre for Clinical Research, Uppsala University, Vasteras, Sweden. [email protected]

The objective of this study was to evaluate the effect of 2 different degrees of mandibular advancement, 50% vs. 75% of maximum protrusive capacity, on somnographic variables after 1 year of dental appliance treatment in patients with mild to moderate obstructive sleep apnea (OSA). A further purpose was to compare the number of adverse events on the stomatognathic system. In a prospective study, 74 male patients were randomly allocated to receive a dental appliance with either 50% (38 patients) or 75% mandibular advancement (36 patients). After 1 year of treatment, 55 patients completed the follow-up. Somnography was performed to measure treatment effects before and 12 months post-treatment. The apnea, apnea/hypopnea, and oxygen desaturation indices decreased significantly in both groups after 1 year (P < 0.001); however, there were no differences between the groups. Normalization (apnea index < 5 and apnea/hypopnea index < 10) was observed in 79% in group 50 and in 73% in group 75. Few patients (< 5%) reported symptoms from the stomatognathic system except for headache (> once a week), which was reported in one-third of the patients. Headache was significantly more infrequent after 1 year of treatment in both groups (P < 0.001). No serious complications were observed except for 2 patients who reported a painful condition from the temporomandibular joint in either group. In conclusion, mandibular advancement with a dental appliance effectively reduces the sleep- Interclass & São Leopoldo Mandic LITOI breathing disorder measured as frequency of apneas, and a pronounced mandibular advancement did not show a greater improvement of the medical problem compared to less advancement for patients with mild to moderate OSA. On the basis of few adverse events in the stomatognathic system or other complications we can recommend dental appliance treatment and, for patients with mild to moderate obstructive sleep apnea, not starting treatment by more than 50% mandibular advancement.

Publication Types: Clinical Trial Randomized Controlled Trial PMID: 14960007 [PubMed - indexed for MEDLINE]

Evidence-based dentistry in clinical practice.

Ismail AI, Bader JD; ADA Council on Scientific Affairs and Division of Science; Journal of the American Dental Association.

Department of Cariology, Restorative Sciences, and Endodontics, School of Dentistry, University of Michigan, Ann Arbor 48109, USA. [email protected]

BACKGROUND: Evidence-based dentistry, or EBD, is not a new concept for the dental profession in the United States. The American Dental Association has long relied on credible scientific evidence in setting policy and communicating with dentists and the general public. EBD provides an approach to oral health care that follows a process of systematically collecting and analyzing scientific evidence to answer a specific clinical question. OVERVIEW: The authors discuss applications of systematic review findings to everyday clinical practice and explore the implications of EBD for dental education, clinical research and the provision of care to patients. CONCLUSIONS AND PRACTICE IMPLICATIONS: In developing appropriate treatment plans, dentists should combine the patient's treatment needs and preferences with the best available scientific evidence, in conjunction with the dentist's clinical expertise. To keep pace with other health professions in building a strong evidence-based foundation, dentistry will require significant investments in clinical research and education to evaluate the best currently available evidence in dentistry and to identify new information needed to help dentists provide optimal care to patients.

PMID: 14959878 [PubMed - indexed for MEDLINE]